Cervical Radiculopathy and Myelopathy

Wayne Cheng, MD Bones and Spine

Overview • Anatomy • Epidemiology • Natural History • Clinical Presentation • Radiology • Treatment – Non-Op – Operative • OITE Questions Anatomy

• Occiput • C1 Atlas • C2 Axis • C3-C7 Anatomy

• Vertebral bodies of C3-C7 are similar – Function and appearance Anatomy Anatomy

• Occipital atlantal joint – 50% flexion extension • Atlantoaxial joint – 50% cervical rotation Anatomy Lower Mandible C2 C3 C4-5 C6 Anatomy Lower Mandible C2 C3 C4-5 C6 Anatomy Lower Mandible C2 C3 C4-5 C6 Anatomy Lower Mandible C2 C3 C4-5 C6 Anatomy Lower Mandible C2 C3 C4-5 C6 Anatomy

• Disc between bodies of C2-C7 – Outer annulus fibrosus – Inner nucleus pulposus • Force dissipaters • Thicker anteriorly, cervical lordosis Anatomy • Cervical nerve roots exit above corresponding vertebral body C1-C7 – C1 exits b/t occiput & C1 body – C8 exits below C7 Anatomy Neuroforamina

• Anteromedially uncovertebral joint • Posterolaterally facet joint • Superiorly pedicle of above vertebrae • Inferiorly pedicle of below vertebrae • Medially edge vertebral end plates & intervertebral discs Anatomy Neuroforamina • Foramina largest at C2-3 • Progressive decrease in size to the C6-7 level • Nerve root occupies 25- 33% foraminal space Definition

• Radiculopathy – Functional disturbance of spinal nerve root • Myelopathy – Functional disturbance of the spinal cord Vs.

Radiculopathy Myelopathy Incidence Natural History Diagnosis ? Cervical Radiculopathy Risk Factors

• Heavy lifting – > 25lbs repetitively • Smoking • Driving/operating vibrating equipment • Previous trauma 15% Cervical Radiculopathy Epidemiology • Annual incidence • M > F ? .85/1000 • C6 & C7 roots – Peak 4th & 5th decades – most commonly affected – 2.1/1000 incidence • Degenerative changes • Prevalence 3.3/1000 > disc herniation – Less frequent than lumbar spine Cervical Radiculopathy Epidemiology • Younger patients • Older patients – “Soft” disc herniation – Foraminal narrowing – Acute injury causing from osteophytes foraminal – More axial neck & impingement interscapular pain Natural History

• Radiculopathy • Myelopathy – 43% no sx after 4 – Epstein: wks • 36% improve – 30% mild sx. • 20% deteriorated – 27% continue to – Symon: have significant sx. • 67% relentless progression • Lee and Turner 1963 – Clark & Robinson: BMJ • 50% deteriorated. Differential Diagnosis Cervical Radiculopathy • Tumors – Intracranial – Axillary schwannoma – Osteochondroma • UE mononeuropathies – Radial – Median – Ulnar • Thoracic Outlet Syndrome Differential Diagnosis Cervical Radiculopathy • Brachial Plexus disorders • Primary shoulder disease – Rotator cuff – Adhesive capsulitis – Glenoid cyst • Epidural varicose veins • Vertebral artery dissection • Infections Referred Pain Distribution

– Osteophytes • Uncovertebral or Facet joints – Disc herniation • Central or Lateral extrusion – Combination Clinical Presentation History • Radiating arm pain • Sensibility loss • Motor deficits • Reflex changes Clinical Presentation History • Disc herniation after – Trauma – Repetitive activity – Awaken at night • Pain – Severe – Burning – Tooth-ache quality • Dysphagia Clinical Presentation History • Dermatomal distribution • Example: C5-C6 Disc – b/t vertebral body C5 + C6 – C6 nerve root compression • Presenting symptoms – Level of nerve compression HISTORY

• 65 year old male , failed B. CTR and B. RCT Surgery. • 54 year old male, WC, failed posterior foraminotomy. Physical Exam

• Sensation • Motor strength • Range of motion • Deep tendon reflexes Physical Exam C4 Radiculopathy • C3-4 level • Uncommon • Weak deltoid • Variable sensory loss • Often severe radiating pain – shoulder & scapula • Rule out rotator cuff dz Physical Exam C5 Radiculopathy • C4-5 level – 3rd most common • Weak deltoid, shoulder external rotators – perhaps biceps • Biceps reflex • Pain & Sensory loss – lateral shoulder – lateral brachium Physical Exam C6 Radiculopathy

• C5-6 level • Weak biceps & wrist extension • Brachioradialis reflex • Pain & sensory loss – radial hand – lateral brachium Physical Exam C7 Radiculopathy

• C6-7 level • Weak triceps, wrist flexion, finger ext • Triceps reflex • Pain & sensory loss – middle finger – posterolateral arm Physical Exam C8 Radiculopathy

• C7-T1 level – Infrequent • Weak grip • Pain & sensory loss – ulnar hand – forearm Physical Exam T1 Radiculopathy

• T1-2 level – Very uncommon • Weak hand intrinsics • Pain & sensory loss – ulnar forearm – elbow Physical Exam Provocative Tests • Spurling Test • Manual Cervical Distraction • Valsalva Maneuver • Shoulder Abduction Sign • L’hermitte’s Sign Physical Exam Spurling Test

• Extending the neck • Rotating head • Downward pressure on head • Positive if pain radiates to side patient’s head is pointed – Positive Spurling in 71% football players c recent burner (Levitz et al AM J Sp Med 1997) Physical Exam Manual Cervical Distraction • Supine patient • Gentle manual axial distraction – Up to ~30lbs • Positive response reduction neck and limb symptoms Physical Exam Valsalva Test

• Patient bears down • Increased intrathecal pressure • Symptoms reproduced Physical Exam Shoulder Abduction Sign • While sitting, patient places hand of affected extremity on head • Support of extremity in scapular plane • Positive test is reduction of symptoms Physical Exam L’hermitte’s Sign • Neck flexion • Electric-like sensation radiating down spine and/or extremities – Cervical spondylosis – Multiple sclerosis – Tumor Clinical Presentation Myelopathy • Gait changes • Bowel(18%) or bladder(15%)dysfunction • Simultaneous LE changes – sensory or motor • Diffuse hyperreflexia – Upper motor neuron changes • 20% no neck or arm pain Hoffman’s Reflex Myelopathy • Suddenly extend middle finger DIP • Reflex finger flexion • When asymmetric indicative spinal cord impingement Inverted Radial Reflex Myelopathy

• Tapping of distal brachioradialis tendon • Spastic contraction of finger flexors Grip & Release Test Myelopathy

• Form fist and extend fingers rapidly • Repeat 20x in 10 seconds Finger Escape Sign Myelopathy

• Hold fingers adducted and extended • Small & ring fingers fall into flexion abduction – Usually within 30 seconds Radiology

• Radiographs • Myelogram • CT Scan • CT Myelogram • MRI • Electrodiagnostics Radiographs Cervical Radiculopathy • Only initial screening tool – Rule out other insidious diseases • Osteophytes – Oblique views • Uncovertebral hypertrophy • Subluxation – Lateral flexion extension Radiographs Cervical Radiculopathy • 30% asymptomatic individuals over 30 yo will have degenerative changes • 70% by 70 yo will have degenerative changes on x-ray Myelogram Cervical Radiculopathy • Intrathecal contrast then X-ray • Assess space occupying lesions by changes in contour – Dural sac – Nerve roots – Spinal cord Myelogram Cervical Radiculopathy • Infection risk • Difficulty distinguish nature of defect – Cervical disc herniation – Osteophyte • Often used in conjunction with CT CT Cervical Radiculopathy • More sensitive than MRI to bony changes • Limited ability to detect soft tissue lesions • Ionizing radiation CT Myelogram Cervical Radiculopathy • Myelography followed by CT scan • Better detect bony and space occupying lesions – Better anatomic information than MRI? • Risk radiation & infection MRI Cervical Radiculopathy • Noninvasive, often only study needed • More sensitive to changes disc, spinal cord, nerve root & surrounding soft tissues – 25% asymptomatic patients > 40yo findings of HNP or foraminal stenosis Radiology Data Cervical Radiculopathy • Blinded retrospective • Correctly predicted cervical spine surgical pathology – MRI 88% – CT Myelo 81% – Myelography alone 58% – CT alone 50% Brown et al Am J Neuroradiology 1988 Treatment Non-Operative Operative • Rest • Indications • Immobilization • Anterior Approach • Medication • Posterior Approach • Physical Therapy • Results • Cervical traction • Injections Non-Operative Treatment Cervical Radiculopathy

• First line therapy – Neck pain – Cervical radiculopathy • Most do well in 6 weeks – 25% persistent or worsening of symptoms Immobilization Cervical Radiculopathy

• Soft cervical collar • Limits range of motion • Minimize nerve root irritation • Relieve paraspinal muscle spasm – Hopefully reduce inflammation Medications Cervical Radiculopathy

• NSAIDs – First choice – Reduce nerve root inflammation • Narcotics • Oral steroids • Local steroids • Epidural steroids Injections Cervical Radiculopathy

• Epidural steroids • Root injections • Facet blocks – Less often than in lumbar spine – Anatomic considerations – Experienced staff Physical Therapy Cervical Radiculopathy

• Cervical Traction • Aerobic exercise • Postural awareness • Spinal extensor strengthening • Thermotherapy • Acupuncture Cervical Traction Cervical Radiculopathy

• Soft disc herniations – Often younger patients • Less successful – Spondylosis – Narrow spinal canals • 20-30lb usually effective distractive force • Long-term basis – select patients Non-Operative Treatment Cervical Radiculopathy • Response in days to weeks • Protracted non-op care not recommended in presence of – Persistent, severe pain – Weakness – Major sensibility loss – Myelopathy with obvious cord findings Operative Treatment Indications

• Compression of nerve • Failed medical root or spinal cord management • Instability • Significant neurologic – Spondylolisthesis deficit – Retrolisthesis – motor weakness • Deformity • Severe cervical myelopathy Approach

• Anterior • Posterior – ACDF – Foraminotomy – Corpectomy • Soft lateral disc.

– Laminectomy – 1 or 2 level dz. – Laminectomy + fusion • (central or lateral) – Laminoplasty • Hard or soft disc – 3 or more levels with – Kyphosis preservation of lordosis. Anterior Approach Cervical Radiculopathy • Supine on table • Left sided approach – if C4-5 or lower – Recurrent laryngeal nerve • Can utilize either side if above C4 Anterior Approach Cervical Radiculopathy • Recurrent laryngeal nerve on left – Predictable course – Between trachea and esophagus – Ascends from looping around aortic arch Anterior Approach Cervical Radiculopathy • Once at spine level, spinal needle place into disc space • Lateral radiograph take to confirm location Anterior Approach Cervical Radiculopathy • Technique described by Robinson & Smith 1955 – Use tricortical iliac crest graft Cloward Technique Cervical Radiculopathy • Dowel type graft • Variable size, bicortical • Sized drill hole carefully placed into center involved disc space Bailey & Badgley Cervical Radiculopathy • Trough made into vertebral bodies – Above and below involved disc • Unicortical – ½ inch width – 3/16 inch depth Simmons & Bhalla Cervical Radiculopathy • Keyhole technique • Beveled bicortical graft – 14-18 degrees ideal – Bevel up for superior vertebral body – Bevel down for inferior vertebral body ACDF

• 42 yo with both C6 and C7 radiculopathy Posterior Approach Cervical Radiculopathy

• Described two decades b/f anterior popularized • Utilized in numerous situations – Lateral soft disc herniation – Midline spondylotic myelopathy Posterior Approach Cervical Radiculopathy • Radiculopathy without neck pain • Keyhole foraminotomy – Lateral discs Posterior Approach Cervical Radiculopathy Raynor et al Neurosurg 1983 • 3-5mm nerve root exposure • 1/3 removal facet joint

• Similar anterior decompression – work outside direct vision Posterior Approach Cervical Radiculopathy Raynor et al J Neurosurg 1985 • 50% B facetectomies • 70% B facetectomies • 5mm nerve root • 8-10mm nerve root – exposure – exposure • Spinal stability intact • Significant reduction of spine stability to shear ANT. CORPECTOMY & POST FORAMINOTOMY • 59 yo businessman with severe R. arm pain.

Posterior Approach Cervical Myelopathy

• Laminoplasty – Stenosis Cervical Laminoplasty

• 81 year old with quadriparesis, loss of function of all 4, worse with BUE than BLE. Combined

• 42 year old with progressive quadriplegia in the ER Combined Combined

• 64 year old male, loss function of right arm, unsteady gait. Combined OITE OITE 2000-#73 • A 45yo man has had spontaneous neck and right arm pain for the past 2 days, and he states that the pain is relieved when he places his hand on the top of his head. Examination reveals decreased sensation on the dorsum of the first web space, weakness in the wrist extensors, and an absent brachioradialis reflex. The remainder of the exam is unremarkable. What is the most likely diagnosis? 1—Double-crush phenomenon with carpal tunnel syndrome & cervical disk herniation at C5-6 2—Cervical disk herniation at C6-7 3—Cervical disk herniation at C5-6 with myelopathy 4—Acute cervical disk herniation at C5-6 5—A shoulder impingement lesion & cervical disk herniation at C6-7 OITE 2000-#73 • A 45yo man has had spontaneous neck and right arm pain for the past 2 days, and he states that the pain is relieved when he places his hand on the top of his head. Examination reveals decreased sensation on the dorsum of the first web space, weakness in the wrist extensors, and an absent brachioradialis reflex. The remainder of the exam is unremarkable. What is the most likely diagnosis? 1—Double-crush phenomenon with carpal tunnel syndrome & cervical disk herniation at C5-6 2—Cervical disk herniation at C6-7 3—Cervical disk herniation at C5-6 with myelopathy 4—Acute cervical disk herniation at C5-6 5—A shoulder impingement lesion & cervical disk herniation at C6-7 SAE Spine 2000 #2 • A 60yo man underwent an anterior diskectomy and fusion for C4-5 disk disease using a left-sided approach 1 week ago. He now reports a persistent dry cough and mild horseness. Pulmonary evaluation shows evidence of a mild aspiration, and ear, nose, and throat visualization shows laxity of the vocal cord on the left side. What is the most likely explanation for these findings? 1—Traction on the recurrent laryngeal nerve 2—Traction on the superior laryngeal nerve 3—Injury to the pharyngeal nerve branches when ligating the superior thyroid artery 4—Direct trauma to the larynx from retractor blades 5—Direct injury to the vocal cords from endotracheal intubation SAE Spine 2000 #2 • A 60yo man underwent an anterior diskectomy and fusion for C4-5 disk disease using a left-sided approach 1 week ago. He now reports a persistent dry cough and mild horseness. Pulmonary evaluation shows evidence of a mild aspiration, and ear, nose, and throat visualization shows laxity of the vocal cord on the left side. What is the most likely explanation for these findings? 1—Traction on the recurrent laryngeal nerve 2—Traction on the superior laryngeal nerve 3—Injury to the pharyngeal nerve branches when ligating the superior thyroid artery 4—Direct trauma to the larynx from retractor blades 5—Direct injury to the vocal cords from endotracheal intubation OITE 1999-#24 • An otherwise healthy 79yo woman has had deteriorating function in her hands for the past 6 months when she is knitting or buttoning. She also reports neck pain and stiffness and diminished sensation in the left hand. Examination reveals a broad-based gait, weakness in the interossei in the left hand, a positive left Hoffman sign, and bilateral upgoing toes. What is the most likely diagnosis? 1—Syringomyelia 2—Pathologic fracture of C4 with incomplete spinal cord injury 3—Amytrophic lateral sclerosis 4—Multiple sclerosis 5—Cervical spondylotic myelopathy OITE 1999-#24 • An otherwise healthy 79yo woman has had deteriorating function in her hands for the past 6 months when she is knitting or buttoning. She also reports neck pain and stiffness and diminished sensation in the left hand. Examination reveals a broad-based gait, weakness in the interossei in the left hand, a positive left Hoffman sign, and bilateral upgoing toes. What is the most likely diagnosis? 1—Syringomyelia 2—Pathologic fracture of C4 with incomplete spinal cord injury 3—Amytrophic lateral sclerosis 4—Multiple sclerosis 5—Cervical spondylotic myelopathy